Perspectives on Surveilling Policy, Systems, and Environmental Change Impacts of Health-Promoting Behaviors in Rural Communities: A Qualitative Study

Rural United States (U.S.) residents typically have lower access to health resources and greater chronic disease risk than urban counterparts. Policy, systems, and environmental (PSE) change strategies can facilitate equitable access to health-promoting resources and improve health-promoting behaviors such as breastfeeding (BF), healthy eating (HE), and physical activity (PA). This qualitative study grounded in the Social Ecological Model examined how PSE strategies promoting BF, HE, and PA are tracked in rural communities. Nine practitioners, representing eight states, were interviewed in August 2020. Participants' organizations included Cooperative Extension (n = 4), non-Extension SNAP-Ed (n = 1), county health department (n = 1), and other community organizations/coalitions (n = 3). A 31-item interview guide based on a PSE framework was developed to assess PSE changes, evaluation strategies, and challenges pertaining to BF, HE, and PA in rural communities. Synthesis coding was completed using a content analysis framework to summarize reported surveillance-specific information, systems, tools, methods, and needs. We identified three themes around rural community needs: (1) localized, accurate, and feasible surveillance methods to assess PSE changes; (2) systems assistance with data collection and monitoring; and (3) easier access to their own and comparison communities' data to inform decisions. Robust systems are required for data collection, monitoring, and analysis to evaluate the effectiveness of PSE change strategies. Greater surveillance/evaluation infrastructure and capacity in rural communities will help ensure these communities have access to data to inform PSE change strategies. Surveillance methods are also needed that extend beyond individual-level behaviors to track the impact of PSE factors on population health.